1. Electronic Prescribing
Jill Mulderig

2. Objectives: Describe Electronic Prescribing
Discuss tools and information system needed
Evaluate the Nurse Informaticist role in EMR/Electronic Prescribing
Discuss safety, ethical and confidentiality issues
Discuss Advantages/Disadvantages with Electronic Prescribing
These objectives are the objectives I will be working on throughout the semester while adding to this project. I have found a number of journal articles that elaborate on electronic prescribing and the EMR; which e-prescribing is a part of.

3. Electronic Prescribing or E-Prescribing is:
Computer based mode of communication
Electronic mode of generating prescriptions
Part of the growing Electronic Medical Record (EMR)
Designed for improved communication with pharmacies and to reduce errors.
Commercially available software- can be used with or without EMR.
(Finkelstein, 2006)
Electronic prescribing is a computerized way to generate prescriptions through an automated data-entry process utilizing e-prescribing software and a transmission network which links to participating pharmacies. This technology is part of the growing EMR. It can also be utilized as a stand alone program as needed. Much work and research needs to be done on evaluation of these programs; because there is little regulation on these programs and most Quality Assurance is done by the companies themselves. What seemed to be first thought of as a system for large hospitals is now readily available to private physicians and in rural areas. For many theorized reasons, it is not as widely used in the US as it is in other areas. In the US, “less than 17% of primary care physicians routinely use EMR’s in their practices” (Anderson, 2007). E-Prescribing is just a small portion of what the Electronic Medical Record may entail. Many include laboratory , pharmacological, radiological, decision support systems and record keeping systems to name a few. Variability exists among different environments using these systems, which is why a program more tailored to the specialty or physician is needed. Physicians, IT personnel, nurses, facilities and other staff all play a crucial role to the success of an EMR implementation and the success of these programs in the health care systems. (Miller et al, 2005). Electronic prescribing and EMR are just a small example of the massive technology available in health systems.

4. Main Goals of E-Prescribing:
Reduce medication errors
Improve patient safety
Increased access to medical information
Improved reporting ability
Cost and time effectiveness
( Barber, Cornford, Klecun 2007)
These are just some of the many goals and gains from using e-prescribing and the EMR. Studies suggest that an electronic medical record that utilizes computerized physician order entry can reduce medication errors, reduce prescription errors, improve compliance and assist physicians with alerts for medications which may interact or counteract with each other. These electronic health systems can reduce many errors and reduce medical costs over time. (Anderson, 2007). Time effectiveness would be seen among nursing staff because the nurses would be able to spend more time with direct care and less time on the telephone. There would be an improved reporting ability because the physicians and nurses would have more information readily available and in order rather than obtaining a file and skimming through it.

5. Hardware for E- Prescribing Can be used with :
Laptops
Desktop PC’s
Pocket PC’s
Tablet PC’s
PDA’s utilizing a wireless network
One does not need all of these to begin e-prescribing. It is part of the EMR, however it is utilized many alone if the EMR is not available. Some physicians may use it only on their Personal Digital Assistant or may use it with both their office computers, laptops, and PDA’s.

6. Personal Digital Assistant (PDA)
Handheld computer with many similar functions
Works with an operating system
Personal computer needed for syncing data and updating.
Organizing while mobile
Compatible with innumerous programs and software titles.
(Carmack, Freudenrich, 2003)
The PDA has many uses such as a calendar, address book, task-list programs, wireless connection to the Internet (E-prescribing is done through a wireless connection), ,  MP3 players, digital photography, games, and some are also used as cell phones. Some PDAs can even have GPS devices. PDAs usually have infrared ports that allow users to "beam" information to each other and it can connect wirelessly to a computer network if it is available. PDAs are also usually able to exchange information with full-sized computers. You can transfer information from your pda to your personal computer and vice versa. (Carmack, Freudenrich, 2003)

7. PDA’s in E-Prescribing
Valuable tool to have all information needed at hand
Information can be saved to sync with office computer
Software easily compatible with PDA’s
Time saving
Helps eliminate written errors
Great start for streamlining to the EMR
Electronic communication between physicians and pharmacists
It is said many offices or smaller offices are not ready for the EMR. The E-prescribing software is a good start to the transition. It a step into the electronic medical record solution. More information is in the physicians hand which can reduce errors, save time, and increase patient satisfaction. It can reduce many errors that come about from handwritten prescriptions. ( Barber et al, 2007).

8. Software for E-Prescribing
Commercially available software
Physician or provider chooses based on preference
Many assist with patient tracking, ICD-9 codes, interactions, pricing, and warnings.
Work with desktop computers, laptops, PDA’s, and tablet pc’s.
Accurate drug databases in tune with health insurances
(nationalerx, nd)

9. Commercial Software Vendors
SureScripts
RxHub
ProxyMed
MedicWare
National E Rx

10. eRX Software:
National ePrescribing Patient Safety Initiative (NEPSI) was enacted due to the large number of medical errors in the healthcare system.
Free program to all physicians and medication prescribers
Created through an advocacy initiative – with
Claims to be simple, safe, and secure
Designed to increase patient safety and reduce errors.
Designed from funding to assist physicians in the advanced technology without the high costs to them.
(nationalerx, nd)
Although there are tons of electronic prescribing software companies and titles available; I found this the most intriguing because it is free. “This coalition-based program is comprised of healthcare, technology and provider companies dedicated to positively impacting the national prescribing process through electronic prescribing (ePrescribing) delivery. NEPSI delivers on this commitment by offering free ePrescribing to every physician and medication prescriber in America” (nationalerx, nd)

11. E RX software is designed to:
Eliminates handwriting issues and error
Creates electronic records to ensure prescription information is saved.
Reduces healthcare costs by improving efficiency and identifying generic drug options
Checks for allergies, drug interactions, dosing errors, and many other patient specific factors
Maintains an comprehensive drug database
Expedites prescription refill requests and saves staff time
Provides up-to-date formulary and insurance information
Improves data exchange between pharmacists and prescribers
(nationalerx, nd)
These are just of the few major advantages to electronic prescribing utilizing the software. It is free through this health initiative, yet not everyone is taking advantage of the opportunity. Other software may have more or less added benefits. Each are tailored in their own way.

12. Included in the free program:
Partnership with ALLSCRIPTS and PocketScript
Six months of connectivity available (cell data exchange or high speed internet access available
Cell phone and WAN option available
Installed access area - connected to either DSL or cable high-speed internet
(Mandel, Boulter, nd)
The free program is expected to spread throughout the US and other countries. The actual software title used would be developed and based on the state it will be used in. Other key players involved in the spread, would get involved based on their funding and interest.

13. Usability of Software:
The system appears to be user friendly for both beginners and experts with minimal training.
Pilot program in 2001 for physicians to evaluate
Two pilot projects confirmed better ease of use and usability for physicians.
There is an iterative design – which can cause less anxieties.
There are icons and visual aids for the users to see.
Workarounds possible but less likely
Cognitive work analysis- program was developed under influence of physician’s concerns.
(Mandel, Boulter, nd)
The pilot studies done to evaluate this software program prompted those involved to consider the adaptation to other technologies and developed a collaborative on how they can adapt to these new technologies (Mandel, Boulter, nd).

14. Evaluations on Usability
A pilot study with a focus group was enacted before release.
Collaborative is staffed by members of involved organizations for feedback.
Forums and meetings for prescriber education and training (cognitive walkthrough).
Evaluation after pilot to discuss and change
Study found a decrease in ER visits and reduction in safety errors.
Positive feedback received would indicate positive usability.
Qualitative evaluations done via studies to evaluate
(Mandel, Boulter, nd)
The study and pilots were done to evaluate the effectiveness and usability before the release of the software. 15 sites were selected with a total of 113 providers (Mandel, Boulter, nd). Prescribers, pharmacists and office personnel provided good overall satisfaction ratings to the software program. Providers felt the software decreased the amount of time spent on prescriptions, as did pharmacists. Identification of patient disease processes and medications helped to improve ratings for overall care. There was an increase in knowledge of available generic medications for patients to help with their costs. Medical costs for the pilot increased but the program is expected to decrease overall costs over time. The e-Rx collaborative is joined by three key agencies (Tufts Health Plan, Blue Cross Blue Shield of Massachusetts, and Zix Corporation- which provides the virus management. (Mandel, Boulter, nd). While states may adapt to certain software titles funded and contracted through government agencies; the program is beginning to gain use and is expected to be similar to each other. While I could only see so much with pictures and a small demo; the program seems fairly easy to use and I am not an expert by any means. Every article I have viewed discuss the importance of better regulations on the software on the market. Many titles do their own research and regulatory mechanisms which can lead to bias.

15. Information System
E-prescribing is an information system that is available as a stand alone configuration.
It is also part of a larger information system- Electronic Medical Record (EHR)
Many use e-prescribing as a starter or part of the electronic transition into the EMR.
Many facilities use eprescibing as a means of transition for their facilities into the EMR. Cost is a major factor as well. Many will utilize the prescribing and examine and evaluate responses before deciding to get into the use of the EMR. A main factor is the use of the EMR and why providers are not utilizing it more is cost. It is costly; even though it is shown to cut costs over time.

16. Clinical Information System: EMR
EMR is an electronic record with ability to generate a complete record of a clinical patient & supporting care related activities through an computerized interface.
Use specific software to personalize specific needs.
Many programs can be altered or adjusted to fit the facilities needs. Nursing aspects can be added or deleted depending on the use of the system. There are many different programs and the facility needs to research their needs and compare to find an information system that fits their needs.

17. Electronic Medical Records: Medicware
Clinical information system
EMR and components are used by physicians, nurses, hospitals, support staff, billing departments, and other personnel
Available in many configurations such as workstations, Tablet PC’s, and servers.
Networking capabilities
Some information available on PDA
With electronic records; possibilities appear endless. You can transfer records, get up to date information, instant lab reports, and communicate with other providers amongst many other capabilities. Different types of software have different capabilities and programs to be used.

18. Electronic Medical Records
Computer-based
Systematic documentation of a clients health status and health care in a secure format
Can be processed, stored, transmitted, and accessed by authorized professionals for the purpose of supporting efficient, high quality health care and accurate sharing of information across the continuum
(McGonigle, Mastrain, 2009)

19. MedicWare EMR Software System
Clinical Information System
Centralized computerized patient medical record software
Streamlined diagnostic and treatment processes
Available online or via software purchase
Houses data and information regarding the health status of a client
(Medicware, 2008)
This is medical software that provides secure access to patients’ records anytime. It can  eliminate common errors associated with misread prescriptions, missed drug allergies or drug interactions. MedicWare electronic medical record software updating ensures that patient charts are updated and completed in a timely manner, including labs, authorizations, radiology, referrals and health maintenance (Medicware, 2008). It appears top have many security features as well.

20. Components to Medicware include:
Clinical Data Repository (CDR)
Clinical Decision Support System (CDSS)
Electronic Prescribing with Alert messages
Medical Vocabulary
Evidence-based decision support with outcome reporting
Billing and scheduling
HIPAA compliant
Automated task management
Nurses notes
Patient Education materials
Quality management and control
HL7 interface
(Medicware, 2008)
The program I chose to review only uses NANDA for the Nurse’s note. It appears NIC and NOC may now be available for add on as I noticed a question in the help section in regards to NIC classifications. This system also boasts amenities such as billing exporting  or sending CPT/ICD codes that are generated from the patient visit, super bill options, demographic importing, schedule importing,  It also has real time updating, templates and patient summary report (Medicware, 2008). There is also the ability to compare prices of drugs, generic availabilities and check coverage with insurance formularies.

21. Data Standards for Medicware:
American National Standards Institute (ANSI)
Healthlevel 7 (HL7)
Continuity of Care Record (CCR)
(Medicware, 2008)
HL7 provides a standard for the sharing, exchange, integration, and retrieval of electronic health information. HL7 promotes the use of standards among healthcare organizations to increase the effectiveness and efficiency of healthcare delivery. (HL7, 2008) Standards still need work and more governing. Most programs follow the above standards. However, many use their own quality assurance systems and mechanisms rather because as of now there are no specific rules standardizing this practice. Government is now getting more involved in these practices and I think with the growth of informatics and computerization; stronger governing rules will follow.

22. Classifications compatible with Medicware:
ICD-9, ICD-10 - International Statistical Classification of Diseases
CPT – Current Procedure Terminology
SNOMED – Systemized Nomenclature of Medicine
HCPCS - Healthcare Common Procedure Coding System
NANDA – used only for nursing SOAP notes
(Medicware, 2008)
This was a complicated aspect of the assignment. While the EMR is a clinical information system used by many physicians, nurses, staff, and support staff; what is available and what is utilized can differ depending on the program and facility needs. ICD-9, 10 is used to classify diseases, symptoms, and health problems recorded on health and vital records including death certificates and health records (CDC, 2008). It is also used for billing and data tracking purposes. The EMR’s are structured based on facilities needs. Classifications can be added or removed based on choice and usage. The Perioperative data set may be in place in the electronic system used in a surgical facility while it would not be added or utilized in an office setting. It is tailored to fit the needs of the operators. While hospitals may use NANDA. NIC and NOC; a physicians office may only use NANDA. The need for these terminologies depends on the structure and organization. The NANDA, NIC, and NOC are collectively called the NNN terminologies. AN article I read says all three used together in the EMR can cause some problems and confusion. In order to decrease the level of confusion, then combined the NOC and NIC into associated classes and then integrated NANDA. Their classes consisted of diagnoses, physiological functions, life processes, interventions, outcomes, coping, safety, and behavioral which covered the primary nursing categories and more (von Krogh, Dale, Naden, 2005). It appears with the EMR software's, altering which categories are used is available. SNOMED is a computerized, systematic form of medical terminology used to keep the language physicians use the same to prevent error. It is basically a unified list of terminology used to prevent error by using different terms to mean the same thing. The framework utilized can differ among different needs of facilities. This is why I found this aspect to be complicated. IN the main article I read in regards to the NIC, NOC, and NANDA; they found the framework they utilized by integrating NIC, NOC, and NANDA had the potential to contribute to nursing research and education. It also could enhance nursing documentation immensely and reduce stressors on the job (von Krogh, 2005).

23. EMR advantages to Nursing:
Promoting standardized nursing language and terminology
Error reduction
Improve medication safety
Fast, clear access to patient information
Time saving
This specific program seems more doctor friendly. Although it does have Nurses’ SOAP notes with NANDA diagnosis; that is where the nursing criteria is met. Nurses in office settings would be the primary users of for sending billing information to the billing offices so the ICD-9 coding right there is great for nurses who perform this function. Also, nurses do majority of medication ordering when medications are prescribed , so the eprescribing with alerts can help the nurses avoid lengthy phone calls and follow-ups. Nurses could have most information up front to discuss with patients care, educate, print materials, and alert the physicians. Nurses, once they are used to these systems can save time of handwritten documentation, meaning more direct care time with patients. Errors are reduced related to legibility of handwriting. Nursing terminologies will be clear cut to reduce the misunderstanding of what is written. Medication records available to see when last doses were given and to compare with orders. Old records available to nursing staff for review and comparing. All patient information is accessible to the nursing staff to avoid long phone calls and call backs. Many errors can be reduced just by having all clinical information handy. Lab tests will be readily available. Alerts can also help nurses reduce medication errors.

24. E-Prescribing Advantages
Cost saving (over time)
Time saving
Error reduction
Medication Tracking
Easy access
Better formulary compliance
Provider/Nurse mobility
Improved quality of care
The use of e-prescribing is on the rise. It is a cheaper, easier alternative to instituting an EMR right into a practice. It is a way to ease physicians and staff into the technological advances to be made in medicine and nursing. E-prescribing is being utilized to increase safety, quality and efficiency in the delivery of healthcare services. Patient information is easily portable from one health care provider to another using eprescribing and ultimately the EMR. These electronic health systems can reduce many errors and reduce medical costs over time. (Anderson, 2007). Time effectiveness would be seen among nursing staff because the nurses would be able to spend more time with patients and less time looking for charts, calling ion medications, and clarifying orders. There would be an improved reporting ability because the physicians and nurses would have more information readily available to them. I can tell the benefits of a properly introduced and maintained program can outweigh disadvantages; more education and training is needed for those interested in advancing their practices.

25. E-prescribing Advantages:
Possible Medicare bonuses for e-prescribing
There is talk that in 2009 doctors can earn additional money from Medicare if they use electronic prescribing systems in an attempt to reduce errors and injury to patients resulting from errors.

26. Disadvantages/Barriers to e- prescribing
Staff resistance
Cost
Security concerns
Lack of IT staff
Technology Mistrust
Possible reduction in staff
(Anderson, 2007)
While hospitals may have IT staff or personnel specifically educated to handle issues of the above nature; many smaller practices and physicians do not. I feel a partnership with larger institutions can assist these physicians and smaller facilities to feel more confident about utilizing these services. Some laws such as the anti kickback law may prevent bigger institutions from this type of partnership. (Anderson, 2007) Security of [patient information remains a large concern. Many individuals till see technology as an enemy and need to be educated on the advantages of technology. A standardized HIPPA complaint set of rules and regulations are needed for everyone to follow. Guidelines for net security and steps to avoid security breaches are also necessary. Staff needs proper education and time before services are implemented in order to gain trust and reduce resistance. Although you will need an IT or IN for the technological position most likely; you will see a reduction in file room or record room staff because there will be less of a need once all information is computerized. Of course this is seen as a cost saving measure for an institution or office but

27. Ethical & Legal Issues:
Security
Privacy Concerns – HIPAA
Legal barriers
(Anderson, 2007)
Many companies and physicians fear that data and privacy is not secure; especially with the use of wireless internet. Legal barriers may exist related to certain government and state laws related to inability, malpractice and fraud. Some companies do collect information for third parties for reference, quality assurance, and other factors. Some fear this can lead to a breach of security and liability to physicians. (Anderson, 2007). I could not seem to find many laws in place that govern eprescribing or EMR. Businesses and physicians have a fear of hacking, viruses that can leak information, and an interception of information during transmission. They need to move forward with assuring physicians this is a step in the right direction and have more laws for the protection of the individual and for the physicians.

28. Informatics Competencies Required for Eprescribing and EMR:
Health information literacy
Privacy and confidentiality knowledge
Technical security knowledge
Basic computer literacy skills
Informatics skills – acquiring, processing, and sharing knowledge
* Above required by the Professional Nurse
(McGonigle, Mastrain, 2009)
(Miller et al, 2005).
These skills would be required by most if not all nurses adapting to the use of eprescribing and the EMR. Much of this information is instilled in us during our nursing programs and training. However, many of us lack computer skills and need additional training. We realized that we use informatics daily, even if we are not nurse informaticists. Also we need to approach new technology with an open mind. NI have the ability to participate in designing and implementing nursing documentation for the future.

29. Informatics Nurse Role: Eprescribing and EMR
Education
Lead projects
Assist in implementation, access and support of eprescribing leading to the expansion to the EMR.
Ensure security processes are correct and in place
Clinical resource person
Facilitates the integration of data, information, and knowledge to support patients, nurses, physicians, and staff.
Assist and lead research
Tech support
(McGonigle, Mastrain, 2009)
(Miller et al, 2005).
The NI can be instrumental to the emerging technological advances and systems to be set in place. The NI can participate in all aspects of eprescribing and EMR from the development of the programs, to the implementation and rollout of the programs. They can also educate the staff, provide IT support, and implement programs to better the compliance. The NI can lead the way from paper charts and ease the transition to eprescribing and EMR use. How I decided what I believe major roles of the NI in eprescribing was reviewing my notes, book, and articles and thinking about what the role of the NI is; and what would be most needed with this trend. Many people are afraid to embrace new technology and lack of training is most likely a major factor for such resistance.

30. SUMMARY With proper implementation eprescribing can:
Reduce medication errors
Increase access to medical information
Reduce cost and increase time effectiveness
Ease into the transition to Electronic Medical Records
Improve patient safety
Increase direct care time to patient
Space Savings
Legibility of Notes – reduce errors cause by
Studies suggest that an electronic medical record that utilizes computerized physician order entry can reduce medication errors, reduce prescription errors, improve compliance and assist physicians with alerts for medications which may interact or counteract with each other. These electronic health systems can reduce many errors and reduce medical costs over time. (Anderson, 2007). It currently is a cheaper alternative than the traditional EMR; and physicians are hoping increased funding becomes available to assist them in this technological trend. Studies have show the implementation if EMR will reduce documentation time and increase direct care time after the adjustment period time is over. This is very important since many hospital complaints from patients are related to less time inpatient and outpatient with clinical staff. (Finkelstein, 2006)

31. Summary Cont: Accessibility of Charts Transcription Costs Savings
Space Savings
Eliminate Staff
Eligibility for Pay-for-performance
Multiple Users Use a Chart Simultaneously
Automatic laboratory and radiological reports
Electronic Prescriptions
System Recovery
Drug to Drug Interaction and allergy interaction checking
The impact of not having immediate access to key information in emergency situations can be serious. Paper medical charts cannot be effectively searched and used to track, analyze and/or chart clinical medical information and processes. Physician's orders and the corresponding results (meds, labs, etc.) can also be issued, saved and maintained much more efficiently in an EMR system. Consolidating and integrating  patient information is a key to quality patient care. It provides a staff, physicians, nurses and other staff  appropriate access to common patient data while maintaining privacy requirements. This can provide timely clinical treatment decisions, tools to better manage the entire process and an overall improved patient experience. ( Barber et al, 2007) . The key it seems from what I am reading id proper pre evaluation of the products you are interested in before the purchase. One should purchase the software that best fits their needs.

32. REFERENCES
Finkelstein, J (2006).E-Prescribing first step to improved safety. Journal of the National Cancer Institute. 98,
Barber, N, Cornford, T, & Klecun, E (2007). Qualitative evaluation of an electronic prescribing and administration system. Quality and Safety in Health Care. 16,
Anderson, J (2007).Social, ethical and legal barriers to e-health. International Journal of Medical Informatics. 76,
Miller, MD, R, Gardner, PhD, R, Johnson, MD, MS, K, & Hripcsak, MD, MS, G (2005). Clinical decision support and electronic prescribing systems: A time for responsible thought and action. Journal of the American Medical Informatics Association, 12,
Carmack, C, Freudenrich (2003, 06, 12). How PDAs work. Retrieved September 30, 2008, from HowStuffWorks.com. Web site:
Retrieved September 30, 2008, Web site:
Anderson, J (2007).Social, ethical, and legal barriers to E-health. International Journal of Medical Informatics. 76,

33. REFERENCES
Mandel, MD, BCBSMA, B, Boulter, MD, P, E-Rx collaborative, E-Prescribing: A bridge to the 21st century. Retrieved October 5, 2008, from Web site:
What is HN7?. Retrieved October 26, 2008, from What is Web site:
Conn , J (2007, February 13). Standards rivals’ collaboration could have major impact. Retrieved October 26, 2008, from EMRAdvice Web site:
2008, September). Retrieved October 26, 2008, from Center for Disease Control Web site:
von Krogh, G, Dale, C, & Naden, D (2005). A framework for integrating NANDA, NIC, and NOC terminology in electronic patient records. Journal of Nursing Scholarship. 37,
(McGonigle, Dee., & Mastrain, Kathleen. (2009). Nursing Informatics and the Foundation of Knowledge. Sudbury, Massachusetts: Jones and Bartlett Publishers)
Medicware Electronic Medical Records. Retrieved November 15, 2008, from Medicware.com Web site: